Healthcare Provider Details

I. General information

NPI: 1629957741
Provider Name (Legal Business Name): SAMANTHA BRAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E BROADWAY ST
MOUNT PLEASANT MI
48858-2647
US

IV. Provider business mailing address

1240 E BROOMFIELD ST APT M3
MOUNT PLEASANT MI
48858-7180
US

V. Phone/Fax

Practice location:
  • Phone: 989-613-7800
  • Fax:
Mailing address:
  • Phone: 906-630-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6352001054
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: